Women & Maternal Health: Annual Report
In 2020, there were approximately 344,821 women of reproductive age (15 to 44 years old) residing in Idaho, which is just over 19% of the total state population. Idaho’s birth rate for the same year was 60.9 per 1,000 women aged 15-44 years old, which is higher than the national rate of 56.0 (CDC, 2020). One half (50%) of women aged 18 to 44 had a preventive medical visit in the past year and 71.2% of females aged 21 to 65 had a Pap test in the past three years. In 2021, 93% of mothers began prenatal care during the first trimester (BRFSS, 2020 and 2021). Idaho does not have a statewide paid family leave statute, although the State of Idaho began providing up to 8 weeks of paid parental leave for employees in July 2020.
For the Women/Maternal Health domain, Idaho has selected “NPM 1: Well-Women Visits” based on the results from the needs assessment indicating the need to focus on routine care for women, including prenatal care for pregnant women. In 2018, 79.7% of pregnant women initiated prenatal care during the first trimester (PRATS). In 2020, a total of 81.4% initiated care during the first trimester and 14.7% did so in the second trimester. By July 2025, the state aims to increase the number of women who are linked to routine well-woman care, including prenatal care during the first trimester. Measurement of the objective will be based on federally available data for Idaho. Strategies to address this objective and NPM are discussed below.
During the 2019 legislative session, a bill was passed tasking the Idaho Department of Health and Welfare with implementation of a Maternal Mortality Review Committee (MMRC). The purpose of this committee is to review maternal deaths to understand the contributing factors and offer recommendations to prevent future deaths. The Idaho MCH Program has been charged with housing and coordinating the MMRC. As a result, the following objective has been added to the state action plan: By September 2025, annually implement the legislatively required MMRC to review maternal deaths in Idaho and offer recommendations for prevention.
A second objective in the Women/Maternal Health domain has been added to support the development and implementation of a Perinatal Quality Collaborative (PQC) by September 2025. The goal is to improve quality of care for mothers and babies based on recommendations from the Idaho MMRC. The addition of this objective will provide the mechanism to act on these recommendations and then implement solutions with a group of stakeholders that can have statewide impact on maternal health outcomes.
To address these two new objectives, the existing priority of supporting “services, programs, and activities that promote safe and healthy family functioning” was used to justify the important addition of MMRC and PQC work to this domain. Based on the 2021 needs assessment, this priority is centered on results indicating the following as priorities for women of reproductive age and pregnant women: preconception health, mental health/substance abuse treatment, access to health care, self-care, parenting education, and prenatal care. Therefore, this priority and objective are linked with national outcome measures (NOMs) related to severe maternal morbidity and maternal mortality, which align with “NPM 1: Well-Women Visits.”
The MCH Program continues to partner with the Idaho Tobacco Prevention and Control Program (ITPCP) to support efforts to direct pregnant and breastfeeding women and women of reproductive age to the Idaho QuitLine. The ESM 14.1.1 in the 2021-2025 state action plan measures the percentage of pregnant women, postpartum women, and their partners who quit smoking through participation in the local public health district cessation program.
This work aligns with the existing priority to decrease substance abuse among maternal and child health populations. The 2021 needs assessment indicated 9.1% of women smoked at any time during pregnancy statewide from 2014-2018. Furthermore, American Indian/Alaskan Native women had the highest rate of smoking during pregnancy at 16.4%. Non-Hispanic women had over two times the rate (10.1%) of smoking at any time during pregnancy than their Hispanic counterparts (4.0%). Women living in remote areas had the highest rate (14.6%) of smoking any time during their pregnancy when compared to rural (9.5%) and urban women (8.6%) in Idaho.
For the Women/Maternal Health domain, Idaho selected “NPM 1: Well-Women Visits” based on the results from the needs assessment indicating the need to focus on routine care for women, including prenatal care for pregnant women. By July 2025, the state aims to see an increase in the number of women who are linked to routine well-woman care, including prenatal care during the first trimester. Measurement of the objective will be based on federally available data for Idaho. Strategies to address this objective and NPM are discussed below.
The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program and the Idaho Family Planning Program (IFPP) are administered within the Maternal and Child Health Section which allows for better alignment of home visiting, family planning, and Title V MCH priorities. In 2017, the MCH Program collaborated with the Family Planning Program to integrate One Key Question® (OKQ) into their service delivery. OKQ is an evidence-based strategy that encourages providers to ask clients the question, “Would you like to become pregnant in the next year?” as part of routine care. This process is designed to incorporate pregnancy intention screening into reproductive health and primary care settings as a proactive way to increase the proportion of pregnancies that are wanted, planned, and as healthy as possible. By asking the question, clients are supported in their decision-making, and clinicians can provide education and services that are tailored to the desires and needs of each client. Client responses, along with education and referrals, are captured in the EHR and reviewed during chart audits as a quality assurance measure. Idaho Title V funded the contract with the national model developer to offer web-based training to Title X network providers.
From January 1 to December 31, 2022, a total of 4,760 female unduplicated clients and 374 male unduplicated clients were screened for pregnancy intention using the OKQ approach. Based on these data, 77.5% (5,134/6,621) of family planning clients were assessed for pregnancy intendedness using OKQ (ESM 1.1). Of those screened, 3.4% responded with “Yes,” 70% responded “No,” 2.3% responded that they were “Okay either way,” and 2% indicated they were “Unsure.” About 22.3% of unduplicated clients were not asked during the current visit about their pregnancy intention. Providers are asking OKQ within a range of frequency from every three months, every six months, or annually. It may not be appropriate or necessary to ask a client at every visit, which contributes to the 22.3% that were not asked. Additionally, while some sites are having great success with asking OKQ, one FQHC has expressed difficulty in their staff completing this assessment consistently. They have verbalized an increased effort to ensure clients are asked OKQ during each Title X visit by ensuring staff are properly trained and the electronic medical record is set up to accurately document this assessment. As of December 2022, four public health districts and two FQHCs are using OKQ to screen for pregnancy intention across 43 service sites.
The MCH block grant continued to provide funding to the IFPP to support subgrants to four of the seven local public health districts and two federally qualified health centers (FQHCs) which provide family planning services on a sliding-fee scale in accordance with Title X regulations to women of reproductive age, as well as adolescents and men. About 19% of clients served were adolescents under the age of 20, and about 10% were male. Family planning services at the local level include reproductive health exams, pre- and inter-conception health planning, pregnancy testing and counseling, preventive health education, and provision of contraception. It’s worth noting that three health districts have elected to no longer deliver Title X services. In October 2018, IFPP initiated subgrants with two FQHCs in southwestern and south-central Idaho to provide Title X services in areas that had family planning service gaps. These FQHCs added 15 clinic sites serving residents in 11 counties to the IFPP Title X network.
In 2022, the local family planning programs served 6,621 unduplicated clients: 6,103 females and 518 males. Among these clients, 1,041 received pregnancy tests. A total of 184, or 18%, of these women received a positive pregnancy test, and 91, or 49%, were given a referral to prenatal care. Five (5) women, or 0.5%, were given a referral for high-risk pregnancy care. In total, 96 women who were in need of prenatal care were referred when need was indicated.
In the IFPP, women who receive a positive pregnancy test are offered a variety of information based on their disposition during the visit. If a client was planning the pregnancy, desires the pregnancy, or seems clear about wanting to continue the pregnancy, the client receives a packet which includes a list of prenatal care providers who accept Medicaid, as well as information about Medicaid and WIC. If a client seems unsure about the pregnancy, the same packet is offered with a list of prenatal care providers, Medicaid and WIC information, and other options are discussed. In Public Health District 7, a program called Medicaid Ineligible Pregnancy Services (MIPS) helps pregnant women who are Medicaid ineligible navigate the prenatal process. Medicaid ineligible women include non-residents such as international students, refugees, and migrants. Women are given a list of prenatal care providers who will accept the Medicaid rate, which would be paid out-of-pocket. These women can get their prenatal lab work through the health district, which is less expensive than through a private provider. MIPS also includes paperwork to get a Medicaid Emergency Card for post-delivery.
In 2019, the IFPP began a collaboration with the Sexual Violence Prevention (SVP) Program within the Division of Public Health to provide regional training opportunities for Title X providers using the Futures Without Violence curriculum, Did You Know Your Relationship Affects Your Health? This curriculum is a train-the-trainers model that addresses intimate partner violence (IPV), reproductive coercion (RC), and sexual coercion (SC). This innovative approach focuses on the crucial role of health care providers in identifying and addressing IPV, RC, and SC in the clinic setting. The curriculum provides training, tools, and resources to help health care providers address these complex and sometimes uncomfortable issues. The training demonstrates how to use a safety card to educate clients about RC and SC during Title X family planning visits to improve reproductive health outcomes and promote safe and healthy relationships. Safety cards and other resources for integrating and sustaining a trauma-informed, coordinated response to IPV, RC, and SC are provided to participants during the training.
COVID-19 Impact on Well-Women Care
Over the course of 2022, COVID-19 continued to impact IFPP services levels. Since the start of COVID-19, the program has seen fewer IFPP clients each year (2020-2022). The program is working to return to pre-pandemic service levels through promotion of the Title X Clinic locator tool, telehealth, and community engagement activities. Subrecipients have implemented telehealth visits with minimal results due to the need for annual exams, STD screenings, and other preventive health screenings (e.g., Pap smears) that need to be conducted in-person. Subrecipients have also been unable to restore clinical services at women’s and juvenile corrections facilities because outside partnerships continue to be prohibited. Additionally, staffing shortages and turnover that started during the pandemic continue to persist, which limits subrecipients’ ability to offer extended clinic hours to reach more clients.
IFPP expects that service levels will gradually improve, and the numbers of clients and visits will show conservative but positive gains in 2023. The program is optimistic that reproductive health visits to Title X clinics will grow due to subrecipients offering telehealth, same-day-appointments, and affordable access to effective contraceptive methods. IFPP is committed to promoting Title X clinics across Idaho to help prevent unintended pregnancies. In 2022, IFPP’s Title X funding was reduced by more than 30% and remains flat for 2023. As the IFPP works to restore service levels to pre-pandemic levels, additional funding will be needed to ensure that those most in need of high quality, affordable, and accessible reproductive health care continue to benefit from the important safety net Title X clinics provide.
The Idaho MIECHV Program and Project Director, housed in the MCH Section, is supervised by the MCH Director. The MIECHV Program supports seven local implementing agencies (LIAs) to deliver evidence‑based home visiting services, which have been shown to promote positive parenting, alleviate poverty, and reduce rates of child abuse and neglect. Idaho MIECHV’s goals and objectives include:
- Supporting community-based organizations to implement evidence-based home visiting programs.
- Supporting and training home visiting programs in the integration of home visiting services with services aligned with Title V Maternal and Child Health (MCH) Block Grant goals including – safe sleep education, smoking cessation, breastfeeding, and Adverse Childhood Experiences.
- Supporting home visiting programs in implementing continuous quality improvement practices in their daily work.
The home visiting programs are voluntary and help families with infants and young children from pregnancy through age 5 years old. With MIECHV funding, the LIAs provide home visitation in 27 counties using two evidence-based programs: Parents as Teachers (PAT) and Nurse-Family Partnership (NFP). Service populations vary slightly between programs. For PAT, families may enroll at any point in pregnancy and children may enroll before they enter kindergarten. NFP serves first-time, low-income mothers and infants during pregnancy and continuing until the child is two years old.
A total of 5,260 home visits were provided by MIECHV programs during FY 2022. The home visits included 3,827 in-person and 1,423 virtual visits. A total of 555 families received services during FY 2022. Of these families, 238 were newly enrolled during the program year.
MIECHV LIAs serve many women prenatally, including a total of 91 pregnant women through home visiting services in FY 2022. Of these women, approximately 97% were covered by health insurance and 100% of women in need of prenatal care were referred to prenatal care. Approximately 51% of enrolled prenatal women breastfed their infants for at least six months, a 6% increase from the previous year.
The MIECHV Program continues to offer group and individual Reflective Supervision and Consultation (RSC) sessions for home visitors and supervisors. In group RC sessions, home visitors hone reflective skills and capacity which they in turn model for family caregivers. This is called the parallel process and is critical for infants and young children to learn social-emotional skills impacting school readiness. Idaho MIECHV offers monthly webinars with topics including development of self-care practices, safe sleep practices, and harm reduction to meet families where they are in this process.
COVID-19 Impact on Home Visiting
The technological challenges encountered during the first two years of the pandemic have mostly subsided. Home visitors are adept at determining when virtual home visits are the best option. In FY 2022, 27% of home visits were completed remotely by phone or virtual platforms such as Zoom. Many of the LIAs used MIECHV American Rescue Plan Act (ARPA) funds to purchase appropriate technological devices to allow entering home visiting data while in the field. ARPA funds were also used to hire part-time outreach coordinators, offer grocery cards to families who consistently attended home visits each month, purchase emergency supplies like diapers, warm clothing, and blankets, and purchase vision screeners required for fidelity to the evidence-based home visiting models.
A lack of community partner referrals has been one of the biggest hurdles for home visiting programs during the public health emergency. However, LIAs have seen measurable improvements in the last year and the percent of maximum capacity service (i.e., monthly caseload) has increased from 75% in 2021 to 84% in 2022.
Maternal Mortality Review and Perinatal Quality Collaborative
Since 2005, Idaho’s maternal mortality rate increased from a low of 17.0 per 100,000 live births for 2008-2012 to a high of 23.8 per 100,000 live births for 2012-2016. In 2017 and 2018, the MCH Program was engaged by the Idaho Medical Association (IMA), the Idaho Perinatal Project, the Idaho chapter of the American College of Obstetricians and Gynecologists, and provider champions to discuss maternal mortality review committee legislation. MCH assisted stakeholders with outlining other states’ efforts, reviewing legislation and processes from other states, exploring possible barriers, participating in training, and creating a plan for what maternal mortality review will look like in Idaho. The MCH Program supplied the team with example legislation, provided state-level data, participated in regional ACOG webinars related to the CDC’s MMRIA data system, and shared funding opportunities related to maternal mortality review teams. During the 2019 legislative session, the IMA presented House Bill 109 which authorized the creation and implementation of a Maternal Mortality Review Committee (MMRC) for the state. The bill passed and was signed by the governor, and MMRC work is now being led by the Idaho MCH Program.
In 2019, the Maternal Mortality Review (MMR) Program developed policies and procedures based on the Review to Action resource center, created notification letters to build awareness of the presence and function of a MMRC, and established a fully functioning committee. The MMRC is comprised of 15 members from a variety of specialties and regions in the state and meets annually. The first MMRC meeting was held in March 2020 with all members in attendance and reviewed deaths from 2018. Since its first meeting, the MMRC has successfully reviewed all cases from 2018 to 2021. Committee recommendations and data were presented in the Annual Idaho Maternal Mortality Reports for 2018, 2019, and 2020 with combined data in the appendices of the 2019 and 2020 reports. This report is provided to the legislature each year to share the MMRC’s findings and recommendations. The MMR Program also maintains a webpage on the DHW website to share contact information, resources, and reports with providers and the public.
In Spring 2022, MMR Program staff began engaging in RSC through one-on-one and group sessions with a contracted RSC specialist. The MMR Program also worked with a licensed clinical social worker (LCSW) who is a certified clinical trauma and compassion fatigue professional to provide self-care training and resources to MMRC members.
Also in Spring 2022, the MMR Program began working with Division of Public Health leadership to propose legislation to remove the sunset date in the existing MMRC statute during the 2023 legislative session. The removal of the sunset clause would allow the MMRC to maintain its authorities and protections to continue to conduct comprehensive multidisciplinary reviews of maternal deaths in Idaho. The MMR Program was able to garner additional support of the proposed legislation through engagement of stakeholders from Idaho’s largest birthing hospitals, statewide medical associations, and community organizations.
The MCH Program recognizes that the next step in reducing maternal mortality and morbidity, and putting MMRC recommendations into action, is the establishment of Idaho’s Perinatal Quality Collaborative (PQC). In 2021, the MCH program manager met with other states’ PQC leaders to discuss their structure, funding sources, project selection and adoption processes, and membership. The MCH Program determined that partnering with an external entity will provide more sustainability for establishing Idaho’s first PQC. The MCH Program began the subgrant solicitation process for the Idaho PQC in February 2022 and awarded the subgrant to Comagine Health with a start date of July 1, 2022.
Comagine Health will be responsible for creating a stakeholder engagement plan and making a recommendation to the MCH Program on the best-suited structure for Idaho’s PQC. They will also develop a data management plan to determine the best way to collect and analyze hospital data to improve maternal health outcomes. Establishment of a PQC will provide Idaho with an avenue for reviewing and acting upon MMRC recommendations. It will also put Idaho in a good position to enroll with the Alliance for Innovation on Maternal Health (AIM) and begin implementation of their Patient Safety Bundles. Next steps for the continued development of the PQC are outlined in the FY 2024 application plan.
The MCH Program partners with the Idaho Tobacco Prevention and Control Program (ITPCP) to address substance abuse among MCH populations in the Women/Maternal Health domain. The ITPCP has made it a priority to reach pregnant and nursing mothers who use tobacco and encourage them to make quit attempts. Most of these efforts are focused on directing this population to the Idaho QuitLine and encouraging them to make use of barrier-free, evidence-based, no-cost cessation benefits. The Idaho QuitLine is a telephone and web-based intervention that links callers interested in quitting smoking with nicotine replacement therapy (NRT), behavioral support, and counseling. The Idaho QuitLine is tracking calls for tobacco cessation counseling and referral for pregnant women and women aged 18 to 44 for ESM 14.1.1.
According to the Association of State and Territorial Health Officials (2013), offering pregnancy specific and postpartum QuitLine services to women is a recommended strategy to improve smoking cessation. In 2015, the Idaho QuitLine implemented a Pregnancy Cessation Program, which offers up to 10 calls during pregnancy and postpartum for women who want to quit smoking compared with the 5 calls for the general population. This program also provides participants with a $5 incentive card for each session they participate in before birth and $10 for each session after the baby is born. This enhanced program includes several intervention calls in the two-week period following a quit attempt, one just before the due date and two calls within two months after the baby’s delivery. These calls help the participant to develop skills to remain tobacco free and to reduce the health risks to the baby from exposure to secondhand smoke. Pregnant women may request nicotine replacement therapy (NRT); however, they must obtain approval from their primary care provider. Up to 8 weeks of free NRT is offered through the Idaho QuitLine, if approved through their primary care provider. Any pregnant or new mother that expresses interest in quitting tobacco through the QuitLine is automatically referred to the 10-call Pregnancy Program. For FY 2022, data show a total of 358 women, including 20 who were pregnant or breastfeeding, aged 18 to 44 years called or completed a web intake to the Idaho QuitLine for cessation services.
The MCH Program has strengthened collaboration with the ITPCP to implement a smoking cessation program tailored for pregnant and postpartum women, their partners, and households with young children (under the age of one year) in the seven public health districts and one tribal health center. This homegrown program, modeled from the evidence-based program “Baby and Me – Tobacco Free,” offers diaper incentives for pregnant women, postpartum women, and household members who quit smoking. Program participants who quit smoking during pregnancy, or up to one year after the baby is born, are eligible to receive one box of diapers per month for up to twelve months in order to promote a sustained quit.
When an individual is referred to the Diapers and Wipes Program they are also referred to Health District cessation classes and the Idaho QuitLine to receive counseling support to help them quit smoking or vaping. Once a program participant quits smoking, they are eligible to receive a box of diapers. The participants are tested for nicotine or carbon monoxide, and upon results indicating the person has quit, they receive a box of diapers. If the participant has a positive test, then they will continue to work with the Health Educator to support them in their quit journey. Tobacco Control grant funding supports staff time to promote and implement the program while MCH funds the testing, diapers, and wipes. Evaluation of the expanded program tracks the percentage of pregnant women, postpartum women, or their household members who quit smoking through participation in the program (ESM 14.1.1). Program outcomes are measured by the number of participants who participate in the first test, the number who receive the incentive at the first test, and the number who stay quit throughout the program.
From April 2021 to April 2022, a total of 336 pregnant, postpartum women, or household members participated in the incentive-driven cessation program. A total of 317, or 94%, of pregnant women, postpartum women, and their household members quit as a result of program participation.
COVID-19 Impact on Smoking Cessation
After two years of program disruptions and adaptations, ITPCP reports that COVID-19 did not have a significant impact on the Diapers and Wipes Program during the reporting period. The local public health districts were able to resume in-person cessation classes and the Idaho QuitLine continued to be available 24 hours per day, seven days per week.
Other Activities
The Reproductive and Adolescent Health Unit, housed in the MCH Section, oversees state-mandated activities related to pregnancy education for women seeking abortion services. By Idaho law, the Idaho Department of Health and Welfare is required to develop and distribute packets of fetal development materials for women contemplating abortion which must be provided within 24 hours of the procedure. This activity was tasked to the MCH Program in 2013. The three booklets in the packet include information on fetal development, the abortion procedure and associated risks, and a directory of pregnancy and child health services. During the 2016 legislative session, the law was amended to add a list of providers that would provide a free ultrasound to a woman contemplating abortion. This list is maintained and distributed by the MCH Program. During the 2018 legislative session, the law was amended requiring that information regarding abortion reversal (for medical or chemical abortions) be included in the packet. In 2018, the MCH Program translated the packet materials into Spanish to be more accessible. The Spanish version is available in hard-copy and online. In 2021, the bill was further amended to provide information about the development of children with Down syndrome and resources available in the public and private sector to assist parents with the delivery and care of a child born with Down syndrome. Electronic copies of these booklets and lists are maintained at www.abortioninfo.dhw.idaho.gov.
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